Health Care Flexible Spending Account (HCFSA ... - nyc.gov

1 Health care Flexible Spending Account (HCFSA) Program Your Welcome Kit Includes ~ Important Website Information ~ How to Submit HCFSA Claims ~ Instructions for Submitting Claims During 2019 Grace Period ~ Claims and Reimbursement Procedures ~ Monthly Claims Payment and Quarterly Statements ~ Over-the-Counter (OTC) Drug Claims (with prescription only). ~ HCFSA Claims Form ~ Medical Necessity Form ~ HCFSA Program HIPAA PHI Authorization Form Procedures Guide Plan Year 2019. Please visit the Flexible Spending Accounts (FSA) Program Website at for detailed information on: The Dependent care Assistance Program (DeCAP).

2 The Health care Flexible Spending Account (HCFSA) Program The MSC Health Benefits Buy-Out Waiver Program The MSC Premium Conversion Program You can select Forms & Downloads for: Plan Year 2019 Brochures and Enrollment/Change Forms FSA Program Claims Forms Medical Necessity Form HCFSA Program HIPAA PHI Authorization Form FSA Direct Deposit Enrollment/Change/Cancellation Form Plan Year 2019. How to Submit HCFSA Claims Plan Year and Grace Period: You may file claims from January 1, 2019 through December 31, 2019 for Plan Year 2019. You may also submit claims incurred during the Grace Period (January 1, 2020 through March 15, 2020) using the remaining balance in your Plan Year 2019 Account , if any.

3 Claims Run-Out Period: If you need time to obtain additional documentation from your Health plan(s) and/or Welfare Fund(s) for claims incurred during Plan Year 2019 or the Grace Period, you may file claims from January 1, 2020 through May 31, 2020. The last day to submit all claims is May 31, 2020. Medical Claims #1 - Submit all medical claims to your primary Health plan #2 - Submit remaining expenses to your secondary Health plan or Welfare Fund's Superimposed Major Medical Plan (if applicable). #3 - Obtain Explanation of Benefits Statements (EOBs) from both primary and secondary Health plans #4 - Complete an HCFSA Claims Form for remaining expenses and submit it along with your EOBs Over-the-Counter (OTC) Drug Claims (with prescription only).

4 #1 - Follow the checklist on the OTC drug claims instruction sheet enclosed in the HCFSA Procedures Guide to determine whether the product is eligible for reimbursement #2 - Compile copies of doctor's prescriptions and itemized receipts from OTC drug purchases and indicate recipient's name on OTC receipt #3 - Make copies of product boxes if receipts do not indicate which OTC drugs you purchased #4 - Complete an HCFSA Claims Form and submit it with your receipts and doctor's prescription Office Visit Co-Pays and Prescription Drug Co-Pays #1 - Compile receipts (or EOBs) indicating your co-pays #2 - Complete an HCFSA Claims Form and submit it along with your EOBs or receipts Dental and Vision care Claims #1 - Submit all dental and vision care claims to your union or Welfare Fund #2 - Obtain EOBs from your union or Welfare Fund #3 - Complete an HCFSA Claims Form for remaining out-of-pocket expenses and submit it along with your EOBs Hearing Aid Claims #1 - Submit all hearing aid claims to your union or Welfare Fund's secondary Health plan such as a Superimposed Major Medical Plan (if applicable).

5 #2 - Obtain EOBs from your union or Welfare Fund's secondary Health plan such as a Superimposed Major Medical Plan (if applicable). #3 - Complete an HCFSA Claims Form for remaining out-of-pocket expenses and submit it along with your EOBs Plan Year 2019. Instructions for Submitting Claims During 2019 HCFSA Grace Period What is the HCFSA Grace Period? Previously, under the Use It or Lose It Rule mandated by the IRS, any amount contributed to your HCFSA. but not claimed by the end of the Plan Year was forfeited. Now the IRS permits a Grace Period, which is an additional time period during which you may submit claims for eligible medical services received from January 1 through March 15 following the end of the Plan Year if you have a remaining balance in your previous Plan Year's Account .

6 The Grace Period affords you an opportunity to use any remaining funds without having to forfeit your entire balance after the last day of the Plan Year. The Grace Period during which you may use your remaining balance in your Plan Year 2019 Account is from January 1, 2020 through March 15, 2020. (NOTE: The Claims Run-Out Period described below also applies to claims submitted during the Grace Period.). What is the Difference Between the Grace Period and Claims Run- Out Period? The Claims Run-Out Period, which runs from January 1, 2020 through May 31, 2020 is an additional time period during which you may submit outstanding or pending claims for services received during Plan Year 2019.

7 Or Grace Period 2019. For example: You received a medical service during Plan Year 2019, but did not receive an Explanation of Benefits (EOB). prior to the last day of the Plan Year (December 31, 2019) in order to submit a claim on time. You will have until the last day of the Claims Run-Out Period (May 31, 2020) to obtain your EOB and submit your claim. You received a medical service during Grace Period 2019, but did not receive an EOB prior to the last day of Grace Period 2019 (March 15, 2020) in order to submit a claim on time. You will have until the last day of the Claims Run-Out Period (May 31, 2020) to obtain your EOB and submit your claim.

8 What Happens to My Remaining Balance from Plan Year 2019 if I. Do Not Submit a Claim by May 31, 2020? According to the IRS, if you do not submit a claim incurred during Plan Year 2019 or Grace Period 2019 by May 31, 2020, any amount remaining in your Plan Year 2019 Account will be forfeited. Plan Year 2019. Health care Flexible Spending Account (HCFSA). Program Claims and Reimbursement Procedures Please follow these procedures for the expedient processing of your claims and note that medical care must be for expenses to diagnose, cure, mitigate, treat or prevent disease or to affect any structure or function of the human body.

9 1. Submit your Claims Forms once a month, on or before the last day of the month. (Minimum reim- bursement amount requested must total $ unless current Account balance is less than $ ). 2. Attach the following documentation to Claims Forms: Itemized bill or receipt from service provider, and Explanation of Benefits (EOB) statement (issued by your Health insurance carrier for medical expenses or Welfare Fund for dental, vision and/or hearing expenses, indicating benefits received and services for which payment has been requested). Copy of product box for over-the-counter (OTC) drugs if receipt does not indicate name of the drug, and doctor's prescription.

10 3. Each EOB, bill, receipt, and Claims Form must contain the following information: Name of patient receiving service Amount of charge for service Type of service Name of provider rendering service Date of service Note: The date(s) of service(s) on the Claims Form must match the date(s) of service(s) on the EOB. and the receipt or billing statement. To obtain an EOB for medical, dental, vision, or hearing expenses, deductibles, or co-payments covered by any group Health plan, you must first submit your expenses to your Health insurance carrier and/or Welfare Fund.